Coronary artery disease progression is associated with C-reactive protein and conventional risk factors but not soluble CD40 ligand

Relationship between Syntax Score and prognostic localization of coronary artery lesions with conventional risk factors, plasma profile markers, and carotid atherosclerosis (CAPP Study 2)

BACKGROUND

Data concerning the relationship between cardiovascular risk factors, plasmatic markers, carotid disease and extent of coronary lesions are lacking.

OBJECTIVES

To evaluate the role of cardiovascular risk factors, plasmatic levels of high sensitivity C-reactive protein (hs-CRP), fibrinogen, lipoprotein(a), and carotid plaque extension in predicting the severity of coronary artery disease (CAD).

METHODS

We analyzed 574 subjects undergoing first coronary angiography. For angiographic analysis, we used the Syntax Score and we defined the prognostic localization of CAD as a critical stenosis of the left main and/or proximal segment of left anterior descending artery. Levels of hs-CRP >3mg/L, lipoprotein(a) plasma levels >30mg/dL and plasma fibrinogen >300mg/dL were considered critical. Significant carotid disease (SCD) was defined by the presence of lesions producing a 50% diameter stenosis with a peak systolic velocity >125cm/s. A mean carotid intima media thickness (IMT) >0.9mm was considered abnormal.

RESULTS

In the adjusted analysis the presence of SCD was found to be an independent predictor of high Syntax Score (p<0.001), while high fibrinogen levels were independently associated with the presence of CAD in prognostic localization (p=0.04). In the sub-group of patients without SCD, IMT >0.9mm was found to be an independent predictor of the presence of CAD (p<0.001).

CONCLUSIONS

SCD strongly predicts high Syntax Score, while IMT shows excellent positive predictive value for the presence of CAD. In addition, high plasma fibrinogen levels are associated with coronary stenoses in prognostic localization.

Pathophysiological roles and clinical importance of biomarkers in acute coronary syndrome

Early diagnosis of acute coronary syndrome (ACS) is important to guide appropriate therapy at a time when it is most likely to be of value. Accurate prognostic and risk stratification will facilitate high-risk patients to have early advanced diagnostic investigations and early appropriate interventions in a cost-effective and efficient manner, while those patients at low risk of ACS complications do not need such costly diagnostic tests and unnecessary hospital admission. Recent investigations have demonstrated that elevation of biomarkers upstream from acute-phase biomarkers, biomarkers of plaque destabilization and rupture, biomarkers of myocardial ischemia, necrosis, and dysfunction may provide an earlier assessment of patient risk and identify patients with higher risk of having an adverse event. This review provides an overview of the pathophysiology and clinical characteristics of several well-established biomarkers as well as emerging biomarkers that may have potential clinical utility in patients with ACS. Such emerging biomarkers hold promise and need to be more thoroughly evaluated before utilization in routine clinical practice.

Different Mid-Term Prognostic Predictors of Major Adverse Events in Diabetic and Nondiabetic Peripheral Artery Disease Presenting With Critical Limb Ischemia

We compared midterm prognostic predictors of peripheral artery disease (PAD) with or without diabetes mellitus (DM) presenting with critical lower limb ischemia (CLI). A total of 172 patients with PAD (109 DM; 63 non-DM) were enrolled. The major adverse events (MAEs) were death or amputation. The diabetic group had a higher MAE rate (39% vs 22%, P = .042) with a mean follow-up duration of 30 ± 19 months. In a multivariate binary logistic regression analysis, revascularization (odds ratio = 0.289, P = .006) and higher serum cholesterol (odds ratio=0.988, P = .027) predicted a lower MAE rate in the DM group. In contrast, the presence of severe chronic kidney disease (stage 4 or 5, odds ratio = 5.238, P = .025) was a positive predictor of MAEs in the nondiabetic group. In conclusion, the prognostic predictors of MAE in diabetic and nondiabetic patients with PAD and CLI were different.

The CD40/CD40 ligand system: linking inflammation with atherothrombosis

The role of CD40/CD40 ligand (CD40L) in atherothrombosis is now widely accepted. However, the exact mechanisms linking the CD40/CD40L system and the soluble form of CD40 ligand (sCD40L) with atherothrombosis are currently a topic of intensive research. CD40L and sCD40L belong to the tumor necrosis factor superfamily, and they are molecules with a dual prothrombotic and proinflammatory role. They are expressed in a variety of tissues such as the immune system (in both B and T cells), the vascular wall, and activated platelets. Soluble CD40L has multiple autocrine, paracrine, and endocrine actions, and it may trigger key mechanisms participating in atherothrombosis. CD40/CD40L may participate in the development of coronary atherosclerosis and the triggering of acute coronary syndromes, while sCD40L seems to have a prognostic role not only in subjects with advanced atherosclerosis but also in the general population. Although conventional cardiovascular medication such as antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors, and many others have been shown to reduce both sCD40L and cardiovascular risk, it is still unclear whether specific treatments targeting the CD40/CD40L system will prove to be beneficial against atherothrombosis in the near future.

Long-term percutaneous coronary intervention rates and associated independent predictors for progression of nonintervened nonculprit coronary lesions

After successful percutaneous coronary intervention (PCI), unpredictable coronary events occur that are caused by in-stent restenosis and the progression of preexisting nonculprit coronary lesions. However, little is known about the long-term clinically driven PCI rates for the progression of nonculprit coronary lesions discovered during culprit-lesion PCI or its independent predictors, including several biomarkers. In this study, the clinical and angiographic data of 1,395 PCI patients treated from January 2004 to May 2007 were retrospectively analyzed. Of these patients, 507 were eligible for this study. After baseline PCI (i.e., culprit-lesion PCI), 81 patients (16%) underwent additional clinically driven PCI to treat preexisting nonculprit coronary lesions during the study period. The cumulative rates of clinically driven PCI for nonculprit coronary lesions were 7.7% (n = 39) at 1 year, 14% (n = 70) at 2 years, and 16% (n = 81) at 3 years. The independent predictors of clinically driven PCI included a larger number of significant coronary lesions (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.5 to 3.5, p <0.001), low high-density lipoprotein (<40 mg/dl; OR 2.01, 95% CI 1.01 to 3.98, p = 0.046), hypercholesterolemia (total cholesterol >200 mg/dl; OR 1.46, 95% CI 1.22 to 1.97, p = 0.04), history of PCI (OR 1.24, 95% CI 1.09 to 1.60, p = 0.003), and increased triglyceride levels (OR 1.003, 95% CI 1.001 to 1.007, p = 0.038) at the time of baseline PCI. In conclusion, PCI patients with nonculprit coronary lesions underwent additional clinically driven PCI at rates of 7.7% at 1 year, 14% at 2 years, and 16% at 3 years because of the progression of preexisting nonculprit coronary lesions. Overall coronary artery disease burden and poor lipid profiles at baseline PCI confer significant risks for clinically driven PCI.

The predictive role of C-reactive protein in patients with hypertension and subclinical atherosclerosis

BACKGROUND

Recent guidelines published by the joint European Society of Hypertension/European Society of Cardiology have suggested the inclusion of C-reactive protein (CRP) in the standard assessment of cardiovascular risk in hypertensive patients, but few data are available on the role of CRP in patients with carotid lesions.

METHODS

We studied 472 patients, 236 with and 236 without hypertension, sex- and age-matched, with and without early stages of atherosclerosis (e.g. those with an asymptomatic intima-media thickness of >0.9 mm), the influence of all the other traditional cardiovascular risk factors (e.g. older age, male sex, obesity, diabetes, smoking habit, family history of coronary artery disease, dyslipidaemia) and of high-sensitivity CRP levels on cerebrovascular and cardiovascular events in a 5-year follow up.

RESULTS

At the end of follow up, patients with hypertension had more events than those without (25% vs 17%, P < 0.05). Proportional hazard analysis revealed in the group of patients without hypertension the presence of baseline carotid lesions (P= 0.02) as predictor of events. In patients with hypertension, the presence of baseline carotid lesions (P= 0.04) and elevated CRP levels (P= 0.02) predicted clinical events. Patients with hypertension also showed a significant relationship between clinical events and quintiles of CRP levels (P < 0.01).

CONCLUSION

Beyond the utility of high-sensitivity CRP levels in the prediction of early and late stages of atherosclerosis and subsequently on its association with clinical events, the therapeutic implications of these results remain to be evaluated by further studies.

The incidence and prevalence of extra-articular and systemic manifestations in a cohort of newly-diagnosed patients with rheumatoid arthritis between 1999 and 2006

OBJECTIVE

To evaluate the incidence and prevalence of extra-articular (ExRA) and systemic (SysM) manifestations in a cohort of newly-diagnosed patients with rheumatoid arthritis (RA) in the United States.

PATIENTS AND METHODS

Retrospective analysis using inpatient, outpatient, and pharmacy claims data contained in the Thomson Healthcare MarketScan research databases. Patients >or= 18 years of age with a diagnosis of RA (ICD-9-CM 714.0x) on three non-diagnostic claims on different days between January 1, 1999 and September 30, 2006, and at least 12 months of continuous enrollment prior to, and at least 2 years following diagnosis were included in the analysis. Thirty ExRA/SysM, classified into six groups (cardiovascular, blood, mucosa, pulmonary, other, and non-specific), were evaluated. Patients were followed until in-hospital death, disenrollment, or study end.

RESULTS

A total of 16,752 patients were included (mean age 59.8 +/- 13.5 years; 72.0% female), and were followed up for a mean of 3.9 +/- 1.4 years. ExRA/SysM were experienced by 47.5% of patients, with cardiovascular (27.2%) the most common. The most frequent individual ExRA/SysM was 'other CVD' (17.2%). Female sex was associated with a reduced risk of cardiovascular ExRA/SysM (HR, 0.66; 95% CI, 0.61-0.72), and an increase in mucosa ExRA/SysM (HR, 2.55; 95% CI, 2.03-3.19). Prior treatment with methotrexate (MTX) was associated with significantly reduced risks of cardiovascular (HR 0.65; 95% CI, 0.59-0.72) and blood system (HR 0.71; 95% CI, 0.61-0.82) ExRA/SysM. Other significant associations were also evident: age, comorbidity as measured by CCI and CDS, and geographic region were associated with increased risks for some ExRA/SysM, while prior NSAID treatment and the presence of diabetes were associated with a lower risk for some ExRA/SysM.

CONCLUSION

ExRA/SysM develop in approximately 47% of patients with RA within a few years of diagnosis. Prior treatment with some therapies used in RA management were associated with a reduced risk of developing some ExRA/SysM, while several demographic factors and the presence of comorbidities also affected the risk of developing ExRA/SysM. This analysis was restricted to patients with employer- or government-funded health insurance, while several potential predictors of ExRA/SysM could not be controlled for in the multivariate analysis, as they could not be measured using claims data. Hence, these results may not be generalizable to other groups of patients with RA.

Diabetes exacerbates angiographic coronary lesion progression in subjects with metabolic syndrome independent of CRP levels

BACKGROUND

Metabolic syndrome is gaining more attention as a special cluster of cardiovascular risks. However, its role, with or without diabetes, in predicting atherosclerosis progression, remains largely undetermined. We investigated the predictors for angiographic coronary atherosclerosis progression in patients with metabolic syndrome and angina pectoris.

METHODS

Patients with metabolic syndrome and angina pectoris who underwent repeat coronary angiograms and had serum samples at the time of first catheterization were enrolled for analysis (N=113). A modified Gensini scoring system was used to define CAD progression between the index and follow-up angiograms. Those who had significant angiographic progression of coronary disease were classified as the progression group (N=42) and those who did not as the non-progression group (N=71).

RESULTS

There were more cases of diabetes mellitus (52% vs. 31%, p=0.040) in the CAD progression group. The progression group also had higher baseline fasting blood glucose (150+/-73 vs. 117+/-46 mg/dl, p=0.010) but similar LDL cholesterol (114+/-38 vs. 109+/-33 mg/dl, p=0.421) than the non-progression group. In terms of inflammatory markers, there was no difference in hs-CRP (p=0.208), MCP-1 (p=0.514), or sCD40L (p=0.549) between the groups. In binary logistic regression, diabetes mellitus remained a significant predictor of CAD progression (OR 2.43, p=0.030) for patients with metabolic syndrome and angina pectoris, but hs-CRP and LDL-C were not.

CONCLUSION

Diabetes mellitus, but not inflammatory marker hs-CRP or LDL-C, is a significant predictor of angiographic CAD progression in patients with metabolic syndrome and angina pectoris.

Decreased circulating protective adiponectin level is associated with angiographic coronary disease progression in patients with angina pectoris

Adipocyte cytokines regulate glucose metabolism and insulin resistance and adiponectin is thought to have a protective effect against atherosclerosis. Studies have shown that adiponectin expression is decreased in obese subjects and those with metabolic syndrome or diabetes mellitus. The purpose of this study was to investigate the relationship between circulating adipocyte cytokine concentrations and angiographic coronary artery disease (CAD) progression in patients with chest pain. Patients with stable angina pectoris who underwent repeat coronary angiograms and had serum samples at the time of first catheterization between March 1999 and January 2004 were enrolled. A modified Gensini scoring system was used to define angiographic coronary artery progression between the index and follow-up angiograms. Those who had significant angiographic progression of coronary lesions were classified into the progression group (N=55). Those who did not have CAD progression were classified into the non-progression group (N=102). Univariate analysis showed that CAD progression was associated with male gender (93% vs. 78%, p=0.038), higher baseline total cholesterol (187+/-43 vs. 173+/-39 mg/dl, p=0.037) and higher baseline fasting blood glucose (128+/-57 vs. 110+/-40 mg/dl, p=0.037). Patients in the progression group had a significantly lower serum adiponectin level (14.3+/-7.9 vs. 18.9+/-13.2 mug/ml, p=0.007) than, but resistin (28.9+/-13.4 vs. 34.4+/-26.0 ng/ml, p=0.142) and leptin (7.4+/-4.6 vs. 7.7+/-6.5 ng/ml, p=0.675) levels similar to, those in the non-progression group. In a multivariate binary logistic regression model, male gender (odds ratio 4.283, p=0.015), higher serum cholesterol (odds ratio 1.010, p=0.032) and lower serum adiponectin (odds ratio 0.959, p=0.030) were all significant independent predictors of CAD progression. In conclusion, we found that a decreased circulating level of adiponectin is associated with angiographic CAD progression in patients with angina pectoris.